HospitalInspections.org

Based on record review, observation and interview, the Governing Body (GB) failed to provide oversight and responsibility and ensure equipment needed for the safety of patient surgeries was installed prior to performing surgical procedures in 2 of 2 (Operating Rooms (ORs) #1 and #2) operating rooms in the hospital.

The findings included.

1. The GB failed to ensure the implementation of the Risk Assessments committee recommendation to install a Split unit in the surgical unit in order to prevent the potential for infections.
Refer to C241

Based on policy review, record review, observation and interview, the Governing Body failed to ensure acceptable temperature and humidity levels were maintained prior to performing and during surgical procedures in 2 of 2 (Operating Room #1 and 2) Operating Rooms (OR).

The findings included:

1. The facility's "Environmental Factors" policy revealed, "...Temperatures/Humidity ranges for Surgery Department...OR #1 and #2 humidity: Minimum 30% (percent) Maximum 60%...OR #1 and #2 Temp (temperature) (F/C) (Fahrenheit/Celsius) 68 (degrees) F...Maximum 73 (degrees) F..."

2. Review of the facility's Operating Room Temperature and Humidity logs revealed the following:

OR #1 temperature was out of range 6 of 6 temperature checks in May. Humidity was out of range 1 of 6 checks in May. Temperature was out of range 15 of 19 checks in June. Humidity was out of range 16 of 19 checks in June. Temperature and humidity was out of range 3 of 3 checks in July.

OR #2 temperature and humidity was out of range 6 of 6 checks in May. Temperature and humidity was out of range 19 of 19 checks in June. Temperature and humidity was out of range 3 of 3 checks in July.

3. Review of the facility's 6/15/17 "Risk Assessment" meeting minutes revealed, "Proposed Practice...Improve Humidity Levels in OR...Increased humidity levels in the OR show us out of compliance on many days, with required standard. This increases risk of surgical infections. Surgery supervisor is measuring daily humidity from "built-in" non-calibrated humidity monitor. It was also noted that even with the improved monitor, there are still several days out of compliance...New splits will resolve these too high humidity levels, improve compliance, and decrease the risk of surgical infections. Without the new Split units to decrease humidity levels, OR humidity will remain out of compliance with required standards causing increased risk of infections..." The Risk Assessment meeting minutes documented a request to install would be placed on a list to corporate. There was no documentation of a follow-up to this report and that the Split unit had been ordered and installed prior to further surgical procedures being performed.

4. Observations on 7/5/17 at 11:20 AM in OR #1 revealed a humidity level of 67%. At 11:36 AM the temperature was 64 degrees F and the humidity was 68%.

5. In an interview in the conference room on 7/6/17 at 1:35 PM, when asked about humidity and temperature levels in the OR being outside of the acceptable range, the Quality Lead stated, "...We started talking about the problem in May, but had not started any surgeries because we did not have a surgeon. When we got a surgeon in June we wanted to make sure he was going to stay. We thought the old monitor was incorrect, but with newly calibrated monitor there was not much difference. The surgeon is aware of the problem, as it was discussed during a meeting." The Quality Lead stated it would cost between $30,00.00 to $40,000.00 to install a new Split unit in surgery. The Quality Lead verified the performed 12 surgeries in June, 2017 and 12 surgeries from July 1st through July 6th, 2017.